Q.6 Clinical Case Scenarios - Complete Answers

Case A - Small Bowel Obstruction (SBO)

i) Common Causes of SBO in Adults

• Adhesions - #1 cause in adults (~60-75%); postoperative (most common), postinflammatory, or congenital. This patient's prior episode 2 years ago points to adhesive SBO.
• Hernias - external (inguinal, femoral), incisional, or internal hernias
• Volvulus, carcinomatosis, external neoplasm, intra-abdominal abscess

• Crohn's disease (stricture)
• Primary intestinal neoplasm (e.g. small bowel tumor)
• Intestinal tuberculosis
• Radiation stricture
• Intussusception

• Gallstone ileus
• Phytobezoar
• Foreign body
• Parasite infestation (e.g. Ascaris)

Most likely in this patient: adhesions (prior episode resolving with conservative management = adhesive SBO recurrence).

ii) Initial Management Steps

1. IV Access + Fluid Resuscitation - Insert 2 large-bore IV cannulas; start IV fluids (Normal saline or Ringer's lactate) to correct dehydration. Monitor urine output (target >0.5 mL/kg/hr via urinary catheter).
2. NGT (Nasogastric Tube) Insertion - Decompress the stomach; relieves vomiting, reduces aspiration risk, and allows monitoring of output.
3. NPO (Nil Per Oral) - Strict nil by mouth.
4. Monitoring - Vital signs, urine output, O2 saturation. Pulse oximetry. ECG baseline.
5. Investigations:
   • Blood: CBC, electrolytes, BUN/creatinine, LFT, serum lactate, coagulation profile, blood group & cross-match
   • ABG if indicated
   • Plain AXR (already done - confirms SBO)
   • CT Abdomen with contrast - gold standard; identifies level, cause, and any strangulation/ischemia
6. Electrolyte Correction - Correct hyponatremia, hypokalemia (common with vomiting).
7. Pain Relief - Judicious analgesia (IV opioid if needed); do not withhold.
8. Antibiotics - Broad-spectrum IV antibiotics if strangulation or perforation suspected.
9. Conservative (Non-operative) Management for simple partial SBO:
   • Continue IV fluids + NGT decompression ("drip and suck")
   • Reassess every 4-6 hours
   • If no improvement in 24-48 hours or clinical deterioration - proceed to surgery
10. Surgical Intervention - Indications: complete obstruction, signs of strangulation (peritonism, fever, rising lactate, tachycardia, blood per rectum), closed-loop obstruction, failure of conservative management.
    • Laparotomy or laparoscopy: adhesiolysis, bowel resection if non-viable bowel.

iii) Complications if Not Treated in Time

Case B - Incisional Hernia

i) Most Likely Diagnosis

ii) Risk Factors

iii) Treatment Options

1. Primary Suture Repair
   • Direct fascial closure without mesh
   • High recurrence rate (~50%); reserved for small defects (<2 cm)
   • Not recommended for large or recurrent hernias
2. Open Mesh Repair (with prosthetic mesh)
   • Onlay - mesh placed anterior to fascia
   • Sublay (Rives-Stoppa retromuscular) - mesh placed in retromuscular space (preferred; lowest recurrence)
   • Inlay - mesh bridging the defect (higher recurrence)
   • Significantly reduces recurrence compared to suture repair alone
3. Laparoscopic Repair (IPOM - Intraperitoneal Onlay Mesh)
   • Minimally invasive
   • Preferred for obese patients (like this patient) - reduced wound complications
   • Uses composite mesh (coated to prevent adhesions to bowel)
   • Shorter hospital stay, less pain, faster recovery

For this obese patient with a lower midline incisional hernia: laparoscopic IPOM repair or open Rives-Stoppa retromuscular mesh repair is recommended.

Case C - Upper GI Bleed / Hematemesis

i) Most Likely Diagnosis

• Chronic NSAID use (inhibits COX-1 → reduces prostaglandins → impairs mucosal protection)
• Smoking (impairs mucosal blood flow and healing)
• H. pylori infection (likely underlying; not yet tested)

ii) Differential Diagnoses

iii) Initial Management of Hematemesis (UGI Bleed)

• Secure 2 large-bore IV cannulas (16G or larger)
• IV fluid resuscitation: Normal saline or Ringer's lactate
• Blood transfusion if Hb <7 g/dL or hemodynamically unstable (target Hb 7-9 g/dL)
• Supplemental oxygen; airway protection (consider intubation if massive bleed or altered consciousness)
• Urinary catheter to monitor urine output

• Vital signs monitoring (HR, BP, SpO2)
• NG tube placement - aspirate gastric contents; assess for active bleeding
• Blood tests: CBC, coagulation (PT/INR, APTT), LFT, U&E, blood group & cross-match (hold 4-6 units blood)
• Assess severity using Rockall Score (pre-endoscopy) or Glasgow-Blatchford Score to guide admission and urgency

• Nil per oral
• Stop NSAIDs immediately

• IV Proton Pump Inhibitor (PPI): IV Pantoprazole or Omeprazole 80 mg bolus, then 8 mg/hr infusion (reduces rebleeding by raising gastric pH >6, stabilizing clot)
• IV Somatostatin analogue (Octreotide): if variceal bleed suspected
• Antibiotics: if cirrhosis or variceal bleed

• Within 24 hours for stable patients; within 12 hours for high-risk patients
• Confirms diagnosis (peptic ulcer, site of bleed)
• Provides endoscopic hemostasis:
  • Adrenaline injection (epinephrine 1:10,000)
  • Heater probe thermocoagulation / bipolar electrocoagulation
  • Hemoclip application
  • Combination therapy (injection + thermal/mechanical) preferred

• Continue high-dose IV PPI for 72 hours, then oral PPI
• H. pylori testing (CLO test / biopsy at endoscopy) → eradicate if positive (triple therapy: PPI + Clarithromycin + Amoxicillin for 14 days)
• Recheck Hb at 4-6 hours

• Indications: persistent or recurrent bleeding despite 2 endoscopic attempts, hemodynamic instability
• Procedures: oversewing of the bleeding vessel (ulcer), partial gastrectomy
• Alternatively: Interventional radiology (IR) angioembolization in high surgical risk patients

• Maingot's Abdominal Operations, Table 29-1 (Causes of Mechanical Bowel Obstruction) and pp. 167-169 (Incisional Hernia)
• Sleisenger & Fordtran's Gastrointestinal and Liver Disease, pp. 283-297 (Upper GI Bleeding)
• Schwartz's Principles of Surgery, 11th Edition (Pathophysiology of SBO)